You must own and live in your home for a minimum of 12 months. The property must be located within the Town of Marana incorporated limits

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P r o g r a m R e q u i r e m e n t s

• You must own and live in your home for a minimum of 12 months

• The property must be located within the Town of Marana incorporated limits

• Your income must not exceed the limits listed below. Income from all persons residing in the home MUST be included in the total annual income.

ANNUAL INCOME LIMITS - Roof Repair, Heating & Cooling, Minor Rehabilitation, Septic System Service and Emergency Home Repair

HOUSEHOLD SIZE ANNUAL INCOME

1 Person $29,360

2 Persons $33,520

3 Persons $37,760

4 Persons $41,920

5 Persons $45,280

6 Persons $48,640

7 Persons $52,000

8 Persons $55,360

ANNUAL INCOME LIMITS - Weatherization Program

HOUSEHOLD SIZE

IF YOU ARE AGE 59 OR YOUNGER AND NOT

DISABLED

IF YOU ARE AGE 60 OR OLDER OR ARE

DISABLED

1 Person $11,963 $15,315

2 Persons $16,038 $20,535

3 Persons $20,113 $25,755

4 Persons $24,188 $30,975

5 Persons $28,263 $36,195

6 Persons $32,338 $41,415

7 Persons $36,413 $46,635

8 Persons $40,448 $51,855

*Income limits subject to change

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Housing Rehabilitation Program Application Packet

Owner-Occupied Home Repair

Roofing Septic Systems Weatherization Heating & Cooling Major Systems Repair

Town of Marana

Community Development Department 11555 West Civic Center Drive

Marana, Arizona 85653

(520) 382-1926

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Town of Marana

Housing Rehabilitation Program

Application Instructions

Complete all attached forms. If a page does not apply, write N/A.

YOU MUST SIGN THE PAGE EVEN IF IT DOES NOT APPLY TO YOU; THIS INDICATES THAT YOU HAVE READ THE PAGE.

When you have completed the packet, please return all forms and attachments via mail or in person to:

Town of Marana

Community Development Housing Rehabilitation Program

11555 West Civic Center Drive Marana, Arizona 85653

IF YOU HAVE QUESTIONS, PLEASE CALL (520) 382-1926.

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Community Development Housing Rehabilitation Program

PLEASE COMPLETE THE FOLLOWING PAGES (1-13) AND PROVIDE THE REQUIRED DOCUMENTS AS SOON AS POSSIBLE. IF A PAGE DOES NOT APPLY TO YOU, SIGN THE PAGE AND WRITE N/A. YOU MUST SIGN EVERY PAGE EVEN IF IT DOES NOT APPLY TO YOU. THIS INFORMS US THAT YOU HAVE READ THE PAGE.

WHEN COMPLETED, RETURN THE APPLICATION IN PERSON OR VIA MAIL.

AS SOON AS WE RECEIVE ALL REQUIRED PAPERWORK AND YOUR FILE IS 100% COMPLETE, YOUR APPLICATION WILL BE PROCESSED.

IF YOU HAVE QUESTIONS, OR NEED ASSISTANCE MAKING COPIES, CALL (520) 382-1926. OUR OFFICE HOURS ARE 8:00 AM – 5:00 PM MONDAY THROUGH FRIDAY.

DUE TO THE NUMBER OF APPLICATIONS FOR THIS PROGRAM, THE RELATIVELY LIMITED FUNDING AND THE REQUIRED PROCESSING TIME, THERE WILL BE A WAITING PERIOD FROM THE TIME YOU APPLY UNTIL WORK IS STARTED.

****WHILE THE HOME REPAIR PROGRAM PROVIDES ASSISTANCE WITH COSTLY MAJOR REPAIRS, THE PROGRAM IS NOT DESIGNED TO ASSIST HOMEOWNERS WITH THE FOLLOWING ITEMS: NORMAL MAINTENANCE ISSUES, REMODELING, ROOM ADDITIONS OR ANY OTHER ITEMS SOLELY FOR AESTHETIC VALUE. BOTH CONVENTIONAL AND MANUFACTURED HOMES ARE ELIGIBLE FOR REPAIRS THROUGH THIS PROGRAM.

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Community Development

This packet contains the information and forms necessary to apply for assistance under the Town of Marana Housing Rehabilitation Program.

IN ORDER TO PROCESS YOUR APPLICATION, THE FOLLOWING FORMS MUST BE SIGNED, DATED, AND RETURNED IN THE APPLICATION PACKET:

A. Application (Pgs. 1-4)

B. General Release Form (Pg. 5) Please sign, date and return.

C. Relocation Waiver Form (Pg. 5) D. Social Security Administration (Pg. 6)

If you receive any support from the Social Security Administration, please sign, date, and return. If more than one member of the household receives Social Security payments, please copy and provide a form for each recipient.

E. Employment Verification Form (Pg. 7)

If you (or anyone in your household) are employed, please fill in the employer’s name, address, and phone number, sign and date this form. Your employer may then provide the information needed on the lower half of the form.

F. Income Verification Form (Pg. 8)

If you receive funds from other sources, please fill in your name and Social Security Number (optional) and the name, address, telephone number and your ID# (if any) of this source of other income.

G. Listing of Real Estate Owned/Number of Residences on Property (Pg. 9) Please fill this out completely.

H. Federal Income Tax Status (Pg. 9)

I. Lead Hazard Information Pamphlet Verification (Pg. 10)

Booklet “Protect Your Family from Lead in Your Home” is for your information.

J. Mold Release Form (pg. 10)

Pamphlet “A Brief guide to Mold, Moisture and your Home” is for your information.

Please sign page, date and return.

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K. Physician’s Statement – Handicapped/Disabled Status (Pg. 11)

Complete this form only if you are Handicapped/Disabled, please complete and ask your doctor to complete and sign this form. If you already have a written statement from your doctor, you may include it in the packet in place of this form.

L. Utility History Request Form (Pg. 12)

The person whose name appears on the utility bill must sign this form.

M. Agreement Between Homeowner and the Town of Marana (Pgs. 13)

IN ADDITION, PLEASE INCLUDE COPIES OF THE FOLLOWING DOCUMENTS IN YOUR APPLICATION PACKET.

Copy of last year’s Federal Income Tax return.

Copy of your recorded Property Deed or Land Contract to show evidence of your property ownership. If your deed lists another person’s name as joint tenants with rights of survivorship, and that person has deceased, please include a copy of the death certificate. Mobile home owners must send a copy of the mobile home title. Title must be in your name.

If you receive a monthly check, please provide the following: a copy of that check or a copy of the Award Letter or other documents you have that states the monthly amount you are entitled to receive. If you are sending a copy of an award letter, please send the most recent.

If you are employed, please complete Employment Verification Form page 11 and send copies of your last 3 check stubs.

If you are self-employed, please send income verification for the last 3 months.

Note: Income from everyone in the household must be reported. Violation of this policy may disqualify residents from the program.

When you have assembled all of the above mentioned items, you may return them via mail or deliver them to our office in person. If you have questions, please call the Marana Community Development Department at (520) 382-1926.

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Marana Housing Rehabilitation Application

Homeowner: Date of Birth:

Co-Owner/Spouse: Date of Birth:

Street Address:

City/Town: State: Zip Code:

Home Phone: Work Phone: Cellular Phone:

Email Address:

Language Preference:

Mailing Address: (If Different Street Address)

Street Address:

Town: State: Zip Code:

Number of persons living in home: Adults Children

H o u s i n g I n f o r m a t i o n

Please check the box next to your answer for each of the following questions: (Check all that apply)

Rent or Own:

I own the home I live in

I own the land I live on

I rent the land I live on

Type of Home:

I live in a conventional home

I live in a manufactured home

A portion of my home is a manufactured home

Past Assistance:

Yes No I have received home repair assistance from the Town of Marana in the past.

I purchased my home in: (year) Age of the Home:

How did you hear about the program?

I currently occupy the property that needs repairs: Yes No

*R.V’S/TRAVEL TRAILERS AND MOTOR HOMES ARE NOT ELIGIBLE FOR THE PROGRAM.

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Is your property in a flood zone? Yes No Don’t Know

If your property is in a flood zone, do you have flood insurance on your property?

Yes No (If yes, list agent information below)

Name: Phone No.:

Street Address:

Do you have Homeowners Insurance? Yes No (If yes, list agent information below)

Name: Phone No.:

Street Address:

P e r s o n a l I n f o r m a t i o n a n d F a m i l y S t a t u s

Information of race and ethnicity are gathered for statistical reporting purposes only.

Yes No

Is the applicant a Female Head of

Household?

Is there a disabled household

member?

Is the applicant or a household

member 60 years or older?

Is there a child (children) living in the

household 8 years old or younger?

Race

American Indian or Alaska Native

Check

Box if also Hispanic Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

American Indian or Alaska Native and White

Asian and White

Black or African American and White

American Indian or Alaska Native and Black or African American

Balance/Other

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I n c o m e I n f o r m a t i o n

(Complete all that apply for entire household)

Wages (Monthly) $ Annual Amount $

Pension (Monthly) $ Annual Amount $

Social Security (Monthly) $ Annual Amount $

A.F.D.C. (Monthly) $ Annual Amount $

Real Estate (Monthly) $ Annual Amount $

Other (Monthly) $ Annual Amount $

Total Income (Monthly) $ Annual Amount $

H o u s e h o l d M e m b e r s

Starting with yourself, list ALL household members who live in your home and/or those listed on the property deed as owners. Provide the information requested for EACH person.

Full Name Sex Date of Birth Social Security Relationship Annual Income from All Sources

Income from everyone in the household must be reported. Violation of this policy may disqualify residents from the program.

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H o u s i n g R e h a b i l i t a t i o n S e r v i c e s

You may request any of these services. A Housing Rehabilitation Specialist will assess your home to determine the scope of services that best meet your needs.

Roof Repair (Please specify type of roof)

Shingle Roof Built Up Flat Roof Metal Roof Please describe why you are applying for a new Roof.

Heating and Cooling

Please describe why you are applying for the repair or replacement of your Furnace, Cooler, Air Conditioner and/or Hot Water Heater.

Septic System

Please describe why you are applying for repair or replacement of your septic system.

Emergency Repair

Please describe why you are applying for emergency home repairs.

Minor Rehabilitation

Please describe repairs you need for the rehabilitation of you home.

Weatherization

Please describe why you are applying for repairs which will reduce your utility heating and cooling costs.

Services are provided on an as-needed basis and are subject to fund availability and program eligibility.

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Town of Marana - Housing Rehabilitation Program

G e n e r a l R e l e a s e F o r m

I/We, hereby authorize the Town of Marana

or its designated agents to obtain and receive all records and information pertaining to eligibility for the HOUSING REHABILITATION PROGRAM, including employment, income, (including IRS returns), credit, residency, homeowner insurance and banking information from all persons, companies, or firms holding or having access to such information. This authorization hereby gives the Town of Marana the right to request all information that we can or could obtain from any persons, companies, or firms on any matter referred to above.

I (we) agree to have no claim for defamation, violation of privacy, or otherwise against any person or firm or corporation by reason of any statement or information released by them to the Town of Marana for purposes of the program. The term of this authorization shall commence on the date of signature and be in force for a period of two (2) years.

Signature of Homeowner Date

Street Address:

R e l o c a t i o n W a i v e r F o r m

I/We , Owner(s) of the home located

at: having received a home repair grant

from the Marana Housing Rehabilitation Program, waiver any and all rights I have under the Uniform Relocation Assistance Act. I/We do not require temporary housing and agree to remain in the home during the course of the construction work

Street Address:

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Town of Marana

Housing Rehabilitation Program 11555 West Civic Center Drive

Marana, Arizona 85653 Social Security Administration

3500 N. Campbell, Ste. 100 Tucson, Arizona 85719

Full Name Social Security Number Date of Birth

have/has applied for a housing rehabilitation grant from the Marana Housing Rehabilitation Program. The applicant/s have/has authorized the Town of Marana in writing to obtain verification of the status of the income he/she received from your agency. The requested information is for the confidential use by the Marana Housing Rehabilitation Program. The information needed is the monthly amount received, future increases or decreases in this amount, and the length of time the applicant will continue to receive the income. Please send information in the provided self-addressed envelope.

Request submitted by:

Marana Community Development - Housing Rehabilitation Program 520.382.1900

A U T H O R I Z A T I O N O F A P P L I C A N T

I authorize your agency to furnish the Marana Housing Rehabilitation Program with the information listed above.

Town of Marana

Housing Rehabilitation Program Privacy Act Disclosure Notice

Your Social Security Number is used to verify your income. If you choose not to provide your Security Number your benefits will still be provided, but may be delayed.

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E m p l o y m e n t V e r i f i c a t i o n F o r m

The individual below has made application to the Town of Marana Community Development Department for assistance through the Housing Rehabilitation Program. Your firm was listed as having currently or formerly employed this person. The applicant, by his/her signature below, has authorized you to release his/her employment information. Your assistance in providing employment information will be sincerely appreciated. Thank you.

Employee Name: Social Security Number:

Street Address:

Employer Information:

Street Address:

Date(s) of employment: starting ending

Authorization of Applicant

I hereby consent to the release of my employment verification.

Date:

Signature

Request Submitted By: Date:

Title: Phone: 520-382-1900

Employer’s Information

Employment Dates: (starting) (ending)

Position Held:

Gross Salary or Wage: $ per month week hour If hourly wage, please specify approximate number of hours worked weekly Other Comments:

Signature: Title: Date:

**The above information is furnished in strict confidence, in response to your request**

Please return this form to:

Town of Marana

Community Development Housing Rehabilitation Program 11555 West Civic Center Drive

Marana, Arizona 85653

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Town of Marana

Housing Rehabilitation Program

I n c o m e V e r i f i c a t i o n F o r m

Income Source: Account Number:

Street Address:

Telephone: Email:

What type of income is this?

Full Name SSN# has

applied for the Marana Housing Rehabilitation Program. The applicant has authorized the Town of Marana in writing to obtain verification of the status of the income he/she receives from your agency. The requested information is for the confidential use of the Marana Housing Rehabilitation Program. The information needed is the monthly amount received, future increases or decreases in this amount, and the length of time the applicant will continue to receive the income. Please send information in the provided self-addressed envelope.

Request Submitted By: Date:

Title: Phone: 520.382.1900

I authorize your agency to furnish the Marana Housing Rehabilitation Program with the information listed above.

Signature Date

Town of Marana

Housing Rehabilitation Program Privacy Act Disclosure Notice

Your Social Security Number is used to verify your income. If you choose not to provide your Security Number your benefits will still be provided, but may be delayed.

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Town of Marana

Housing Rehabilitation Program

L i s t i n g o f R e a l E s t a t e O w n e d a n d

N u m b e r o f R e s i d e n c e s L o c a t e d O n P r o p e r t y

Please provide us with the following information:

1. Other housing (mobile home, guest house, etc.) that is located on the property where you now live, by whom it is occupied and the amount of income it provides, if any.

2. A complete list of ALL real estate you own (including your current residence).

Street Address:

Federal Income Tax Status

Check one and sign below:

I/We are not required to file Income tax because

I/We did file Income Tax for the previous year. Copy included packet

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Town of Marana

Housing Rehabilitation Program

L e a d H a z a r d I n f o r m a t i o n P a m p h l e t

Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. By signing below I acknowledge that I have received a copy of the U.S. EPA Lead Hazard Information Pamphlet “Protect Your Family From Lead In Your Home”

Print Full Name Date

Signature

M o l d R e l e a s e F o r m

Mold can be a problem in any home, but especially in those where there is an excessive amount of moisture or humidity present. In addition, homes cooled with evaporative coolers, those occupied by several people, or that have pets, plants, or fish aquariums present, provide excellent conditions for mold to grow. The Town of Marana Rehabilitation Program is not designed to provide direct mitigation of existing mold problems.

By signing this form, I acknowledge that I have received the EPA booklet entitled “A Brief Guide to Mold, Moisture, and Your Home” and that as a participant in the Town of Marana Rehabilitation Program, I agree to hold the Town of Marana and those contracted to make repairs on my home harmless for any existing or future mold problems.

Homeowner Date

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Town of Marana

Housing Rehabilitation Program

P h y s i c i a n ’ s S t a t e me n t

H a n d i c a p p e d / D i s a b l e d S t a t u s

Take this form to your doctor and have your doctor fill it out and return it to you. When completed, attach to your completed application and return to Town of Marana’s Community Development Department.

Name: Date of Birth:

Street Address:

Disability:

I hereby authorize the release of information from my files related to my physical or mental condition to the Town of Marana’s Community Development Department.

Signature Date

Dear Sir/Madam:

The Community Development Department is verifying certain information provided to us by an applicant to Marana’s Housing Rehabilitation Program. We would appreciate your cooperation and immediate attention in providing the information below.

Is patient’s condition: Correct as stated Incorrect as stated (give correct diagnosis):

Is this person considered to be handicapped or disabled? Yes No Length of time patient’s condition is expected to last:

Less than one (1) year. One (1) year or longer and cannot be gainfully employed.

Prior to receiving this form, when did you last see this patient?

Comments/Remarks:

I certify that the information I have given above is full, true and complete to the best of my professional knowledge.

Physician’s Name and Degree Office Phone Number

Signature Date

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Town of Marana

Housing Rehabilitation Program U t i l i t y H i s t o r y R e q u e s t F o r m

Homeowner:

Co-Owner/Spouse:

Street Address:

Home Phone: Work Phone: Cellular Phone:

CHECK ALL THAT APPLY AND FILL OUT INFORMATION REQUESTED

I do not have natural gas service at my home.

I have propane service at my home.

I do not have electric service at my home

I have all electrical service at my home (No gas or Propane)

I have the following electric service at my home: Account Number

Tucson Electric Power Co

#

Trico Electric Co.

I have the following natural gas service at my home:

Southwest Gas Co. #

Other:

I, the undersigned, authorize the above named utility companies to release information to the Town of Marana concerning my utility bills and energy consumption in order to determine savings from the weatherization of my home or for other reasons pertinent to services I may receive through the Town of Marana Community Development Department. I also authorize the future release of information so that the Town of Marana may compare pre-weatherization and post-weatherization usage.

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A g r e e m e n t b e t w e e n t h e H o m e o w n e r a n d t h e T o w n O f M a r a n a

“ H o u s i n g R e h a b i l i t a t i o n P r o g r a m ”

A. HOMEOWNER agrees that the PROGRAM is available for assistance one-time per home.

HOMEOWNER agrees that all future repairs/maintenance become the responsibility of the HOMEOWNER.

B. HOMEOWNER agrees that the PROGRAM shall have final approval authority on all specifications, drawings, and bid requirements prepared for the purpose of soliciting bids.

C. HOMEOWNER agrees that the PROGRAM will have final approval authority on the contractor selection and the resulting contract award.

D. HOMEOWNER agrees the PROGRAM shall represent the HOMEOWNER in the control, supervision and direction of the work to be performed under this contract. A copy of all written communications between the HOMEOWNER and the contractor must be sent to the PROGRAM.

E. HOMEOWNER will not at any time permit changes in specifications or drawings, without prior written approval of PROGRAM.

F. PROGRAM shall have the right at all reasonable times to enter upon the property to observe progress, inspect work, and direct correction of any work which does not comply with the drawings and specifications set forth in the work write-up.

G. HOMEOWNER agrees that upon completion of said work, PROGRAM will have authority to make final inspection and shall have sole authority for final acceptance.

H. HOMEOWNER shall remove all trash, junk and debris from the property prior to

commencement of work and shall maintain the property free from such trash, junk and debris.

I. HOMEOWNER shall be aware that landscaping will be altered due to use of heavy equipment, such as backhoes, and that PROGRAM will not be responsible for re-landscaping or replanting in areas where construction has disturbed the ground.

J. I certify that all the information that I have supplied in this application is true.

K. I hereby authorize administrators of the Marana Housing Rehabilitation Program to request and obtain all information necessary to the process and completion of my application. I understand that all information obtained will be held in strict confidence and used for no other purpose.

L. I have read a description of the program and I understand and agree to comply with the rules and guidelines explained therein.

Street Address

City/Town State Zip Code

Signature of Homeowner Signature of Homeowner

Dated this day of , 20